Maternity Case 2: Brenda Patton,
Documentation Assignments
1. Document your initial assessment data of Brenda Patton, including
uterine activity (frequency and duration), fetal heart rate (FHR) activity
(baseline FHR, long-term variability, accelerations, and decelerations),
vaginal discharge, maternal vital signs, and labs.
o Brenda Patton is an 18 year old Caucasion female G1P0 at 38 2/7 weeks of
gestation admitted to the labor and delivery unit at 2145 with ruptured
membranes and uterine contractions. Her vital signs are as follows: HR – 88,
Pulse – present, BP – 119/71, RR – 20, O2 – 97%, Temp – 98.6, Conscious
state: appropriate. EFM – occasional acceleration. Fetal HR – 141.
2. Document the medication(s) that you administered.
o I administered 5,00,000iu of Penicillin via IV piggyback as per providers
orders.
3. Document Brenda Patton’s pain during labor (severity during
contractions, location, quality, interventions taken, and response to
interventions) and the measures that were taken to promote her desire
for a natural birth.
o Patient reports 2/10 pain between contractions and location of pain
‘everywhere’. Upon assessment the uterus tone was soft between
contractions. Regulatory contractions had started that were moderate in
intensity, approx. 4 minutes apart and lasted 50 seconds. Patient was offered
pain medication but expressed desire to have natural birth without
medications. Nonpharmaceutical methods to alleviate pain were
implemented (therapeutic touch, breathing techniques, attention focusing,
effleurage & massage).
4. Document your handoff report in the situation-background-assessment-
recommendation (SBAR) format to communicate what further care
Brenda Patton needs.
S: Brenda Patton is an 18-year-old G1P0 at 38 2/7 weeks of gestation in active labor
with ruptured membranes and positive GBS status.
B: Brenda has no significant medical concerns with O+ blood. She would like an
unmedicated birth. Pregnancy has been uncomplicated. Patient reports her
From vSim for Nursing | Maternity. © Wolters Kluwer Health.
This study source was downloaded by 100000901307859 from CourseHero.com on 10-15-2025 21:27:44 GMT -05:00
https://www.coursehero.com/file/251819445/BrendaPatton-vSim2-DA-docx/
Documentation Assignments
1. Document your initial assessment data of Brenda Patton, including
uterine activity (frequency and duration), fetal heart rate (FHR) activity
(baseline FHR, long-term variability, accelerations, and decelerations),
vaginal discharge, maternal vital signs, and labs.
o Brenda Patton is an 18 year old Caucasion female G1P0 at 38 2/7 weeks of
gestation admitted to the labor and delivery unit at 2145 with ruptured
membranes and uterine contractions. Her vital signs are as follows: HR – 88,
Pulse – present, BP – 119/71, RR – 20, O2 – 97%, Temp – 98.6, Conscious
state: appropriate. EFM – occasional acceleration. Fetal HR – 141.
2. Document the medication(s) that you administered.
o I administered 5,00,000iu of Penicillin via IV piggyback as per providers
orders.
3. Document Brenda Patton’s pain during labor (severity during
contractions, location, quality, interventions taken, and response to
interventions) and the measures that were taken to promote her desire
for a natural birth.
o Patient reports 2/10 pain between contractions and location of pain
‘everywhere’. Upon assessment the uterus tone was soft between
contractions. Regulatory contractions had started that were moderate in
intensity, approx. 4 minutes apart and lasted 50 seconds. Patient was offered
pain medication but expressed desire to have natural birth without
medications. Nonpharmaceutical methods to alleviate pain were
implemented (therapeutic touch, breathing techniques, attention focusing,
effleurage & massage).
4. Document your handoff report in the situation-background-assessment-
recommendation (SBAR) format to communicate what further care
Brenda Patton needs.
S: Brenda Patton is an 18-year-old G1P0 at 38 2/7 weeks of gestation in active labor
with ruptured membranes and positive GBS status.
B: Brenda has no significant medical concerns with O+ blood. She would like an
unmedicated birth. Pregnancy has been uncomplicated. Patient reports her
From vSim for Nursing | Maternity. © Wolters Kluwer Health.
This study source was downloaded by 100000901307859 from CourseHero.com on 10-15-2025 21:27:44 GMT -05:00
https://www.coursehero.com/file/251819445/BrendaPatton-vSim2-DA-docx/
